Competencies, Certification and Midwifery Basics

I have just over 24 hours to my midwife certification exam. In my midwifery path, certification by exam is a requirement for licensing. But when I get that certification, I will be able to be licensed to practice in any state and it will make my international work a little easier.

Certification and licensing are frequent topics of discussion among my midwifery friends. I have some on both sides of the licensing fence, and on both sides of the certification fence. Due to the crazy nature of this world, not all my friends who think licensing is good are licensed (some are in states without licensing opportunities). Similarly, not all my friends who think licensing is not a good idea are not licensed (some states require licensing to work as a direct entry midwife).

So what about me, where do I land in the debate?

I personally have no problem with certification for midwifery or any profession. Education alone would be nicer (and cheaper), but certification does provide a protection for the midwife consumer and me as the midwifery school consumer. Why? Because I believe knowing your graduates must pass an exam on the basic competencies of a midwife improves the didactic quality of the school. I can’t imagine spending thousands of dollars on a program only to find out it didn’t really give me the information I needed to work independently as a midwife.

I know there are some who feel the certification exam is no proof you are a good midwife, and I agree. Honestly, the only way to be a good midwife is to be a midwife for a few years. I will still be a new midwife, with or without the exam. But the certification exam shows I have a minimum competence with the tools and materials I will be using . It shows I understand the basics of evidence based practice — even if the process of test writing means it will be two to three years behind.

As for licensing, I am a fan. Again, I don’t think licensing makes you a good midwife. It is simply a way for the profession to be regulated — to ensure that all those who are practicing have met the minimum standards. But from the public health side, it does some amazing things. First and foremost, it gets midwives counted. Midwives, especially direct entry, tend to be invisible in research. As long as they are invisible, they will not be taken seriously and their practice will suffer from “evidence” problems. I want to change that.

I also have friends who are against licensing because they feel it restricts their practice. I disagree on two counts.

The first is that every state has a midwifery practice act, and if your practice doesn’t meet the definition your practice is already restricted. If your state’s laws don’t mention midwifery beyond nurse-midwifery it is too easy for your practice to be labeled as illegal. Licensing prevents that.

The second is that I believe midwifery practice (as with any health care practice) should have restrictions. A midwife should be expected to provide evidence based care, even if that means some mothers will be told home birth is not a safe option for them. I believe this as much as I believe physicians should be expected to provide evidence based care, even if that means some mothers will give birth vaginally in the middle of the night on a weekend. I don’t want midwives making their own estimations about which woman is or is not safe birthing at home any more than I want physicians making their own estimations about what is or is not an indication for cesarean. It is too easy to keep moving your own line in the sand.

The current problem is the lack of universally accepted evidence based guidelines – but this I see as a temporary problem. If the system is broken, you fix the system. When you ignore the system completely you lose opportunities to make change (like the problem I have with my research where direct entry midwives cannot really be counted and therefore their impact cannot be estimated).

Change is a slow process, and some of my friends have been waiting too many years (some whole lifetimes) for change. Some have been so burned by past “change” that they have learned to distrust the system. Some gave up fighting years ago, and now just want to do their midwifery without interference from governments or certification organizations. I know this. The sad truth is I don’t personally see a way to move midwifery forward — to extend the rights and protections for direct entry midwives — without causing their practices to be interfered with.

For me, the importance of licensing goes beyond my direct entry friends here in the US. For me, it is also an international thing. Midwives everywhere should have access to good quality training, good and useful tools to do their work, and be paid by the health system for the work they do. For this to happen, midwives need to be a real part of a countries health system rather than an invisible “problem” the health system sometimes ignores and sometimes attacks. Midwives need to be taken seriously. Licensing is one step to being taken seriously.